New memo either could relax rules on collection, or make them tougher

Task still daunting and almost comical’

Editor’s note: In this issue, Hospital Access Management takes a look at access managers’ reaction to a recent change in the rules associated with the gathering of Medicare Secondary Payer information.

Depending on the access manager you ask, the Sept. 25 program memorandum purporting to relax the Medicare Secondary Payer (MSP) data collection rules either does just that . . . or it crystallizes the need for some oppressive, labor-intensive procedures that some hadn’t realized were required.

Part of the confusion appears to stem from the different interpretations of the MSP rules by the various fiscal intermediaries that act as the go-betweens for the Centers for Medicare & Medicaid Services (CMS) and providers.

"For many, this is relaxing the rules; and for others, it’s more restrictive," says Beverly Varshovi, associate director for admissions at Shands Hospital at the University of Florida in Gainesville. "It depends on what they were doing before and what their fiscal intermediary (FI) was telling them."

Great, unrealistic expectations

Even access managers who believe the memo from the CMS does lighten the burden on access staff maintain that the whole business of gathering MSP information is still fraught with unrealistic, if not absurd, expectations.

"It isn’t relaxed enough as far as I am concerned," says Beth Ingram, CHAM, director of patient business services at Touro Infirmary in New Orleans. "The audit trail to prove who you checked the information with on a monthly basis is still very cumbersome, and getting that information on reference lab work is still extremely cumbersome.

"We really thought that would be relaxed or eliminated, but clearly it wasn’t, so I am frankly disappointed," Ingram says.

Policy changes

Basically, the program memorandum outlines these three policy changes.

1. The instructions ease requirements for collecting MSP information for laboratory services when the physician or other provider sends a specimen to the hospital for evaluation, but there is no face-to-face encounter with the patient.

Several access managers told Hospital Access Management off the record that their facilities have never collected MSP data on lab specimens. For those hospitals, this provision is not a benefit — it’s a rude awakening.

The task is less daunting if the hospital lab receives specimens mostly from people who have been patients at the facility, they say, but poses a huge logistical challenge for labs that handle testing for individuals from all over the country who have never been to that hospital.

The revised policy states that hospitals must collect MSP information from a beneficiary or his or her representative for these services, but says that it may use information already collected if it is no older than 60 days.

The dilemma of how best to contact a person whose specimen is being tested at a hospital’s lab remains, notes Peter Kraus, business analyst for Emory University Hospital in Atlanta, although now it has to be dealt with less frequently. Gathering the MSP information for specimens that come in from all over the country poses "an almost comical challenge" for access personnel, he adds.

Calling Medicare recipients whose specimens have been sent to the hospital’s lab and asking them, for example, whether they receive black lung benefits or have had a kidney transplant "is going to generate a lot of confusion from the patient on the other end of the phone," says Barbara Wegner, CHAM, regional director of access services for Providence Health System in Portland, OR.

Those patients, she adds, are likely to react with, "Why is St. Vincent Hospital calling me? I haven’t been to that hospital." And, Wegner points out, all the effort is for what may be a $25 account.

At Shands, access staff do call Medicare patients who haven’t been seen at the hospital, but whose lab work was sent there, and ask the MSP questions, says Varshovi, and it is "very confusing" for those patients.

In another unfair twist, the freestanding laboratories — those not associated with a hospital — don’t appear to be under the same regulations, adds Jeanne Hughes, regional quality assurance and training manager for the Providence system. If dealing with the hospital lab and its MSP questions becomes too much trouble, Wegner notes, Providence customers may decide it’s easier just to send their blood samples to one of those other labs.

Providence’s specimen business is very large — more than 500 samples in a recent one-week period — and only 28% of those were associated with patients who had made a recent visit to the hospital, Hughes says. Wegner estimates she may have to add two full-time equivalents to keep up with the MSP workload.

The Sept. 25 memorandum also states that hospitals should keep an audit trail to show they collected MSP information that was no more than 60 days old when the bills for their Medicare patients were submitted, and should document who supplied the MSP data. What is particularly disturbing to many access managers is that the memo goes on to say that if the hospital’s use of outdated or inaccurate information leads to Medicare making an incorrect primary payment, the hospital will be liable to repay the overpayment. The hospital also can be fined for giving inaccurate information.

"We can receive this information from someone else, but we are still considered at fault if what is given is incorrect," says Hughes. "Now we need a new field in the computer system to document who provided this information to us."

Liz Kehrer, CHAM, system administrator for patient access at Centegra Health System, in McHenry, IL, says she has these immediate concerns with the provision:

• "The lab would need a process to track when MSP data was last collected, with a flag to alert [staff] to the expiration date of the data."

• "What proof does the lab have that a subsequent specimen[s] was ordered for the same reason as when the MSP data was collected?" In other words, Medicare could be the primary payer in one case and secondary in another, she points out.

• "The lab/hospital is still liable for submitting a fraudulent’ claim and is exposed to the problems related — that is, penalties and the risk of jeopardizing Medicare certification — because the provider chose’ not to verify the information."

Kraus notes that he always enjoys his access director’s "disdainful perspective" on the whole MSP concept. "She deeply resents [CMS] making hospitals do what she regards as their work. No other carrier requires the providers of service to determine liability, much less holds the providers accountable if they get it wrong."

It is particularly irritating, he adds, that the MSP requirement isn’t enforced with physician visits.

Collecting MSP data

2. They drop the requirement for collecting MSP information when the beneficiary is enrolled in a managed care plan.

Some access managers — who for obvious reasons did not want to go on record with the apparent oversight — told HAM they were not aware that it had ever been necessary to collect MSP data from Medicare managed care patients.

Others, like Varshovi at Shands Hospital, said they already had discontinued the practice. "We had stopped it last May because we had gotten information that we didn’t have to do it."

It’s one of the items in the memo that is probably most significant, says Anthony M. Bruno, MPA, MEd, director, patient accounts and business operations, at Philadelphia’s Presbyterian Medical Center, because of the volume of patients it affects. But he says his hospital had discontinued the practice in 2000, and the facility where he worked previously — like Varshovi’s — had stopped collecting MSP data from Medicare managed care patients this past spring.

"We worked with our fiscal intermediary, and finally nailed it down," Bruno adds. "They said, I guess you don’t have to do that.’"

A hospital’s experience with MSP and other requirements "depends on the kind of relationship you have [with the FI]," he notes, and whether the FI is forthcoming and communicative or more remote.

The on-line news service AHA News reported in its Oct. 30 issue that Medicare+Choice [managed care] beneficiaries are exempt from the MSP questionnaire. The article stated that the announcement came out of a meeting between what was then known as the Health Care Financing Administration (HCFA) and U.S. Rep Saxby Chambliss (R-GA), who had been pressuring HCFA to change its MSP policy. According to the same article, MSP requirements for hospitals acting as reference labs were to be addressed later.

Access managers who tried to confirm these announcements or get further details, however, told HAM they had difficulty finding the documentation for them, possibly a further reflection of the lack of consistency in FI interpretations and communications.

3. For beneficiaries receiving recurring outpatient services, they require that MSP information be verified only once a month.

Bruno says this information does represent a lessening of the MSP burden for Presbyterian Medical Center. "We’re now doing it on every visit." He adds, however, that his facility does not have a large number of Medicare patients on recurring accounts.

Although Shands Hospital had been somewhat "lax" with collecting MSP data on recurring patients, that changed with the hiring of the hospital system’s director for core billing, Varshovi says. Since that time, she adds, "we have gone by the letter."

The newly hired director, she explains, had been told by a fiscal intermediary in Ohio that getting MSP information on each visit by recurring patients was not necessary, and that hospitals "could be flexible" on the reference lab issue. He had a rude awakening, however, after being called to testify before the Office of the Inspector General (OIG), Varshovi explains.

After arriving at Shands, she notes, "he said, I’m never going before the OIG again. . . . What are you doing about MSP?’"

Similar to its Ohio counterpart, Varshovi says, the Florida FI had also said "common sense" would suggest it was enough to confirm the MSP data with recurring patients before the bill dropped.

After the heads-up from Shands new core billing director, she adds, her department has taken a pro-active approach to the MSP regulations.

"At least every six months, we pull a day’s worth or two days’ worth of Medicare patient accounts in all arenas to make sure [the MSP data] is there," Varshovi says. "The second thing we check for is whether the questions were asked appropriately and documented appropriately."

During these checks — which may involve a week’s worth of data for smaller Shands hospitals — each account is audited and scored for MSP compliance, she says.

Outpatient services

An emphasis at Shands on the creation of financial specialists whose primary function is to create a billable account and do whatever it takes has helped facilitate this process, Varshovi notes. "I have counterparts in community hospitals that struggle with this. While they may have 17 people for 24-hour coverage, there are 50 specialists at my hospital."

Her challenge, she says, is the variety of locations where outpatient services are being rendered. "We are retrospectively trying to gather data, by getting into physicians’ systems and looking at historical data.

"At our facility, all diagnostic testing is hospital-based, but there is a clinic that is wholly owned by the University of Florida," Varshovi adds. "There is no hospital charge — it’s just like the patient saw a physician in the community — but if that physician sends for lab or X-ray, there’s now a [hospital] bill."

Because that patient never came through hospital registration, there is no hospital account, she points out, which means there is no MSP questionnaire, advance directive information, or anything else associated with that patient. Her department is working on a project to reduce those occurrences, Varshovi adds.

Rule stretches computer skills, logic

The need to verify MSP data every 30 days for recurring patients, notes Hughes, means modifications to Providence’s computer systems will be necessary. "Our current system has a verified date,’ but that is for one date per account number. Now I need to show I verified it in March, April, May, and June. The other piece is to document who provided us the information. This will be a significant cost to our system."

At Emory University Hospital, Kraus notes, "from a billing perspective we’d love to re-register every 30 days, but the ancillary department and customer service priorities limit us to 90-day accounts. So the MSP challenge remains in diminished form."

Centegra Health System is in good shape as far as this requirement is concerned, Kehrer says. "We have our recurring/cycle patients set up on monthly accounts. The MSP information is verified on the patient’s first visit of the new month."

There is a discrepancy in logic, Hughes points out, in that MSP information for reference lab specimens has to be verified only every 60 days, while the data for recurring patients must be confirmed every 30 days.

As for her general reaction to the memorandum from CMS, she adds, "I really don’t think they have any idea what reality is in a health care system these days."